Still A Problem
After
successfully declining some 64% over a period of about 13 years,
incidence of gonorrhea actually increased in 1998. While part of the
increase can be attributed to greater vigilance and improved
technology for detecting and reporting the disease, data still
indicate a significant real increase, especially in certain
populations.1
Rates since then have been somewhat more favorable, owing to the
efficacy of the fluoroquinolones; but growing resistance to these
agents brings home the reality that Neisseria
gonorrhea is a very
adaptable organism capable of eluding our best remedies. Around
750,000 cases are reported annually in the United States alone, with
another 750,000 estimated that go unreported.2
Gonorrhea
is second only to Chlamydia (Chlamydia
trachomatis) in incidence
in the United States as a sexually-transmitted disease, and their
comorbidity is a common complication. Since they both cause similar
clinical manifestations and are typically maximally susceptible to
different antimicrobial agents, proper differential diagnosis is
essential for effective treatment. Like many of the STDs,
inevitably, both affect males and females differently.3
In
males, gonococcal urethritis typically causes sudden onset of
purulent discharge and dysuria 2 to 8 days after inoculation,
examination of which shows the characteristic Gram-negative
intracellular kidney-shaped diplococci – usually. Microscopic
examination of discharge from some gonorrhea victims is unremarkable,
more like that with Chlamydia. Occasionally, gonorrhea-infected
males are asymptomatic, and cultures are often inconclusive, a
presentation more common with Chlamydia, where symptoms may be absent
(in 75% of female victims and 50% of male victims)4
or sporadic, coming and going, beginning 7 to 21 days after
inoculation, with or without discharge or dysuria.3
Female
victims of both, though, are more often asymptomatic than not, or at
least only mildly symptomatic. They may not seek treatment, so
cervicitis may only be detected during routine pelvic exams.
Increased mucopurulent endocervical discharge is common to both
infections, with breakthrough bleeding, though erythematous
cervicitis with irregular, raised, and bleeding lesions is more
common with Chlamydia. Urethritis is often present without
occasional dysuria and pyuria with both. Gonococcal pharyngitis,
while usually asymptomatic, is observed occasionally in both sexes,
but most often in homosexual men. Pharyngitis with Chlamydia is a
rare occurrence in either sex, but gonococcal conjunctivitis is
observed in both sexes, as is disseminated gonococcal infection (DGI)
in about 2% of untreated gonorrhea victims, which can lead to septic
arthritis, polyarthritis, and characteristic dermatitis, with
discrete pustules and papules of the extremities in both sexes.
Anorectal
infection is not uncommon with either organism, depending on sexual
practices.
Complications for both
infections include epididymitis in males and endometritis, pelvic
inflammatory disease, and salpingitis in females.3
Swabs
of all symptomatic tissues are necessary for diagnosis. Rapid
nonculture diagnosis has become practical for gonorrhea in many
cases, but tissue culture remains the only definitive means of
identifying Chlamydia. Anyone testing positive for either should
also be tested for syphilis, which can be effectively eradicated
(especially in incubating stages) by appropriate therapy for
concurrent gonorrhea and Chlamydia.
3 (see
below)
Treatment Gonorrhea
While
accurate diagnosis can be a problem, it is by no means the only one
associated with these infections. Gone are the days when penicillin
or ampicillin did the job, as both plasmid- and
chromosomally-mediated resistance have made gonorrhea very resistant
to the penicillins in most of the world;3,5
and the recommended policy of treating with the most effective agent
in optimum doses should be rigorously followed to retard further
resistance development. The
oral fluoroquinolones, ciprofloxacin and ofloxacin are often
effective for uncomplicated gonorrhea;5
but with documented emerging resistance, susceptibility should be
confirmed, and optimum doses should be employed (500mg ciprofloxacin
or 400mg ofloxacin can be given as a single dose, as first-line
choices with acceptable susceptibility).3,6
When the
fluoroquinolones are inappropriate, whether due to resistance,
patient age, pregnancy, etc., the broad-spectrum cephalosporins,
ceftriaxone (125mg IM as a single dose) and cefixime (400mg orally as
a single dose), can generally be relied upon. Ciprofloxacin and
ceftriaxone (and to a lesser extent, cefixime) are generally
preferable for gonococcal pharyngitis.*3
Chlamydia*
For
genital Chlamydia infections, recommended oral regimens include:3
1. Doxycycline
100mg twice daily for 7days
2. Azithromycin
1000mg as a single dose.
Alternate regimens employ:
1. Erythromycin
(500mg base or 800mg ethylsuccinate) 4 times daily for 7 days
2. Ofloxacin
300mg twice daily for 7 days.
For
the pregnant female victim:
1. Azithromycin
1000mg as a single dose
2. Erythromycin
(500mg base or 800mg ethylsuccinate) 4 times daily for 7 days
3. Erythromycin
(250mg base or 400mg ethylsuccinate) 4 times daily for 14 days
4. Amoxicillin
500mg 3 times daily for 7 days are recommended;3
5. Clindamycin may be a suitable choice
when other agents are contraindicated.7
Azithromycin,
erythromycin, and clindamycin are all Pregnancy Category B.8
Concurrent
Infection*
Infection
with both N. gon.
and C. trach.
require adequate treatment for both, combining one regimen from each
of the recommended collections above, taking care to obviate
contraindications. Incubating syphilis will also generally be
adequately treated by such a combination; and patients treated
concurrently for HIV infection can also generally be safely and
effectively treated with these same regimens for gonorrhea and
Chlamydia.
3
* All
recommendations are for uncomplicated infections in adult patients.
Conclusion Untreated,
urethritis caused by both sources of infection tend to subside
spontaneously over a period of weeks or months, but ensuing
complications can be catastrophic. Not only to epididymitis and PID
threaten fertility and ongoing health, but transmission of either
infection to an infant at birth is both common and potentially
devastating to the infant, with both infections causing
conjunctivitis that can lead to blindness and even pneumonia in the
case of Chlamydia.
3
Risk
for both infections is highest among sexually active young adults and
adolescents, and risks increase with lower socioeconomic class and
levels of education, illegal drug use, an urban environment, history
of or concurrent sexually-transmitted disease, and oral contraceptive
use. While oral contraceptive use may simply be an indicator of
sexual activity, hormonal therapy may also act to increase the amount
of endocervical endothelium on the cervical surface, simply exposing
more vulnerable tissue to infection pressures.3
Logical
goals of therapy are 1. to assuage symptoms, 2. to eradicate
infection, 3. to prevent further spread of the infection(s), and 4.
minimize development of resistance in emerging strains of causative
organisms in both local and worldwide populations. Along with proper
treatment of both index cases and sexual contacts, barrier-type
contraceptives can be effective aids in the prevention of spread to
uninfected partners, and spermicides containing nonoxynol 9 have also
proven valuable in limiting spread of not only gonorrhea and
Chlamydia, but candidiasis, genital herpes, syphilis, trichomoniasis,
and AIDS.8
Sources
1. Gonorrhea
Morbidity
& Mortality Weekly Report (MMWR).
Available
at:
http://www.medscape.com/govmt/CDC/MMWR/2000/06.00/mmwr4924.05/mmwr4924.05.html.
Accessed December 20, 2000.
2. Gonorrhea.
National
Institute of Allergy
and Infectious Diseases. http://www.nau.edu/~fronske/gonorhea.html.
Accessed
December 20, 2000.
3, Sexually
Transmitted Diseases. Module 3: Infectious Diseases.
Pharmacotherapy Self-Assessment Program, Third Edition. American
College of Clinical Pharmacy. 1998. pp 45-48.
4. Laboratory
Testing for Gonorrhea. Available at:
http://bugs.uah.ualberta.ca/webbug/bactbug/gclab.htm. Accessed
December 20, 2000.
5. Fluoroquinolone
Resistance in Neisseria
gonorrhoeae. Available
at:
http://respiratorycare.medscape.com/govmt/CDC/EID/1997/v03.n01/e0301.04.knapp/e0301.04.knapp.html#TOC.
Accessed
December 20, 2000.
6. Some
Facts About Chlamydia. Centers For Disease Control. Available at:
http://www.cdc.gov/nchstp/dstd/Fact_Sheets/chlamydia_facts.htm.
Accessed
December 20, 2000.
7. Brocklehurst
P, Rooney G.Interventions
for treating genital chlamydia trachomatis infection in pregnancy
(Cochrane Review). Available at:
http://wwwsom.fmc.flinders.edu.au/FUSA/COCHRANE/cochrane/revabstr/ab000054.htm.
Accessed
December 20, 2000.
8. Contraceptive
Aids. Drug Facts and
Comparisons. Electronic
Edition, November, 2000.
